According to the report, the unnamed resident at St. Benedict's Senior Community died in June after becoming dizzy and unresponsive in the dining room.

The resident had been admitted to the nursing home for a short-term stay following an operation to install a pacemaker because of an irregular heartbeat.

Two nurses never tried to administer CPR — as the patient had directed when she was admitted — even though they were with her from the time she became unresponsive.

When a nurse realized the resident did not have a pulse and was not breathing, the nurse went for a crash cart and informed a supervising nurse that the resident did not have a pulse. The supervising nurse told the nurses not to initiate CPR as the nurses did not witness the resident's arrest and too much time had passed.

A physician said staff members should have initiated CPR according to the orders for full resuscitation, the health department report said.

The nursing home later fired the nurses, who are not named in the report.

Jennifer Vogel, a spokeswoman for the nursing home, said in a statement that St. Benedict's staff members undergo significant training. She said it is unfortunate that the two nurses did not follow it.

"We deeply regret this incident and have expressed our condolences to the family," she said.

Vogel said the nursing home disagrees with the neglect finding but has put together a corrective plan.